Mental health response gaps in South Sudan
A local outpatient clinic in Minkaman, Awerial County, South Sudan
Juba, 17 March 2014 (IRIN) - Aid workers warn that while psychosocial support needs will mount for the tens of thousands of displaced people in South Sudan, the resources and skills needed to treat them are in short supply, and there is particular concern for men, who feel targeted in the ongoing fighting.
South Sudan has been no stranger to conflict in its short two-and-a-half year history. Emerging from a civil war with Sudan, the country, especially restive Jonglei State, has seen regular cattle raids, inter-communal clashes and battles between rebel groups and the national army.
What is unusual this time, according to Miranda Gaanderse, a protection officer with the UN Refugee Agency (UNHCR), is the number of men who fled to UN bases and other relatively safe areas, or left the country entirely. There are still no exact numbers and the majority of displaced are women and children, but Gaanderse said the fact that hundreds of thousands of men have left their home indicates just how violent and traumatic the fighting has been.
The International Crisis Group estimates at least 10,000 people have been killed. An interim UN report on human rights violations found evidence of the targeted killing of civilians, gender-based violence, including gang rape, and torture by combatants on both sides of the conflict.
At least some of the violence seemed psychologically targeted, with agencies reporting bodies were mutilated and left in the middle of settlements to warn people to leave. In places like Bor, capital of Jonglei State, weeks after the fighting stopped, bodies still littered the streets because people were too scared or too scarce to remove them.
“Men were the main targets for violence,” Gaanderse said, and as fighting continues, fear remains. In the displacement camps, she said, it is the women who leave to buy things or collect firewood. “Some men have been sitting there for almost three months. It has a huge impact along WITH psychological impacts.”
In the absence of psychosocial services, she warned that people could turn to alcoholism or violence.
It looks as though they will have no choice but to sit for several more months. A late January cessation of hostilities agreement has been broken multiple times and ongoing peace talks in Addis Ababa have made little progress.
Martin Ojok Karial, a civil servant in Malakal, has been living at the UN base there for more than two months. He said he is “just really angry, because there is no reason… Now nothing happens. No food. No everything. No future.”
Karial has only a few friends to help him process his anger. He said he cannot talk to his family about it.
The sheer immensity of the crisis has left nearly half of the country’s population in need of basic assistance and the clock is ticking: With seasonal rains already started and threating to cut off access to vast swathes of the country soon, humanitarian groups say providing food, clean water and basic medical care has to take precedence over psychosocial support for the time being.
Little donor support
International Medical Corps (IMC) did a rapid assessment of mental health needs in Awerial County and Malakal, the capital of Upper Nile State. They contain populations that have seen some of the worst violence since fighting broke out in South Sudan in mid-December. IMC researchers found a “fragile health system” that was almost completely dependent on international organizations, which do not have the capacity to stage a mental health response.
Displacement camp in Minkaman, Awerial County, South Sudan
The aid community’s emergency response to South Sudan’s crisis is broken down into different categories, called clusters. Psychosocial services fall under the Protection Cluster, which has received only $3.8 million of the requested $63.4 million.
Jorge Castro, who carried out the IMC assessment, could not even attempt to quantify the country’s mental health needs because the current health workers do not have the time or expertise to catalogue them. During his visits, Castro found “people having adjustment disorders and all the spectrum of stresses, anxieties - not just related to this particular event, but to trauma coming from the past. These are huge needs. Everybody is vulnerable. It’s not just about children, women and elders.”
Even before the crisis started, the South Sudan government had no mental health professionals on staff, leaving any psychosocial response to the already overstretched aid agencies.
Fatuma Ibrahim, UNICEF’s chief of child protection, said while they do not have the resources to bring in teams of psychiatrists, there are other interventions they are introducing, though nearly all, given the agency’s mandate, are geared towards children.
These include safe spaces where children can play games or draw under the protection of a trained community member. She said this is a basic way to draw children out and encourage them to talk about what they have experienced.
The problem comes, she said, when a child refuses to participate. “That level of expertise” to engage the child “is still really lacking, to build that capacity. Because now it goes to one-to-one counselling. There are very, very few people with that expertise, that competence.” But she said they hope to be able to reach as many as 90 percent of children at displacement sites with basic psychosocial interventions.
They are also reaching women at markets or other regular, social occasions, to encourage them to talk about their experiences. But the interventions still do not include everyone. “Fathers are usually left out,” she said.
Threat of psychological scars
Rebecca Athou is sitting in the waiting area of a small hospital in Minkaman, cuddling her three-year-old son. The boy developed a small skin infection around his eye, so Athou has brought him for treatment at the outpatient clinic, run by UNICEF. She believes the boy will recover quickly. It is his five-year-old brother she is worried about.
In the midst of heavy fighting in Bor in mid-December, Athou, her husband and three children fled. They crossed the White Nile river and joined the sprawling, temporary settlement that has grown up in Awerial County around Minkaman.
More than two months later, every time Athou’s five-year-old sees “someone holding guns he will call me and tell me, ‘There is someone coming with a gun to kill us,’” Athou said. He rarely sleeps through the night. But there is no place she can take him to get help.
Failing to address trauma can cause a host of problems, said UNICEF’s Ibrahim, including slowed development in children and adolescents and violent outbursts for both children and adults. Ultimately, she said, it can help perpetuate the country’s cycle of violence. The lack of services threatens to leave permanent psychological scars in a new generation, in a country that was barely starting to recover from decades of fighting.